Patient History – Child
Your Name (required)
Date of Birth (required)
Your Phone (required)
Person Completing This Form (required)
Relationship to Client (required)
Mother's Name (required)
Mother's Age (required)
Mother's Address (required)
Mother's City (required)
Mother's State (required)
Mother's Zip (required)
Father's Name (required)
Father's Age (required)
Father's Address (required)
Father's City (required)
Father's State (required)
Father's Zip (required)
List all children in the family from oldest to youngest (Name,age,sex,grade in school, general health)
Child's pediatrician or family doctor
Has the child had any previous testing or therapy for speech, language or hearing problems
Please use the space below to write additional family information that you feel is relevant:
Date and type of last medical examination
Has the child had any ear trouble (such as earaches, infection, running ears, evidence of hearing loss)?
If yes, please describe:
Has hearing been tested?
If yes, please when:
Has the child ever had ear (PE) tubes inserted?
If yes, does the child still have ear (PE) tubes?
Has the child ever worn eyeglasses or had any difficulty with eyes?
Has the child seen a specialist for any reason?
Please use the space below to provide any other important medical information:
Does the child like school?
Does the child like the teacher?
Describe performance in school (please note strong and weak areas)
Does the child attend any special classes (such as speech therapy, language development, reading, resource room, special education classroom)?
Where does the child usually socialize?
Does the child prefer to play alone?
Does the child prefer to play with older or younger children?
Does the child have a close friend?
What are your most frequent discipline problems with this child?
Who does the disciplining?
How do you discipline?
What does the child do well?
What does the child have trouble doing?
Does the child have difficulty concentrating?
Is the child’s speech understandable to;
to you.to friends.to strangers.to other family members?
List sounds or words that the child has trouble saying
How does the child compare with siblings in communication development?
Does the child use words in meaningful ways for his/her age?
Does the child seem to understand directions?
Do you have any further questions?
By signing below, you agree to the following:
1. I agree to have my child screened by a speech language pathologist to ensure proper
2. I understand that my child may not be placed into a group if the speech language
pathologists feels my child is not ready for a social skills group or if my child does not
fit into an appropriate group.
3. I agree to allow graduate students from local universities or other qualified professionals
to observe and participate in treatment sessions, under the supervision and direction of a
certified speech language pathologist.
4. I understand that my $100 deposit is non-refundable unless my child is not placed into a
group per the speech language pathologist. I understand that I am not refunded the money
in the event that I, personally, choose not to have my child participate. By placing a
deposit, I know that I have signed up and secured my group spot.
5. I agree to pay the remaining $250 (group is $350 total) for 8 treatment sessions. I
understand the balance is due before the first session date. Invoices are sent via email. I
can choose to either pay online or send a check via mail to Metro East Therapy at 60 S.
State Route 157 suite 20, Edwardsville, IL. 62025. Checks are made payable to Metro
East Therapy, Inc.
Patient or Parent/Guardian Signature
Relationship to Child
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